Biologicals

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
BEZLOTOXUMAB ZINPLAVA VIAL    
CYTOMEGALOVIRUS IMMUNE GLOBULN CYTOGAM VIAL    
HEPATITIS B IMMUN GLOB/MALTOSE HEPAGAM B VIAL    
HEPATITIS B IMMUNE GLOBULIN HYPERHEP B S-D SYRINGE    
HEPATITIS B IMMUNE GLOBULIN HYPERHEP B S-D VIAL    
HEPATITIS B IMMUNE GLOBULIN NABI-HB VIAL    
IMMUN GLOB G(IGG)/GLY/IGA 0-50 GAMMAPLEX VIAL    
LYMPHOCYTE IG, ANTITHYMOCYTE ATGAM AMPUL    
LYMPHOCYTE IMMUNE GLOB,RABBIT THYMOGLOBULIN VIAL    
RABIES IMMUNE GLOBULIN/PF HYPERRAB S-D VIAL    
RHO(D) IMMUNE GLOBULIN HYPERRHO S-D SYRINGE    
RHO(D) IMMUNE GLOBULIN RHOGAM ULTRA-FILTERED PLUS SYRINGE    
RHO(D) IMMUNE GLOBULIN MICRHOGAM ULTRA-FILTERED PLUS SYRINGE    
RHO(D) IMMUNE GLOBULIN RHOPHYLAC SYRINGE    
RHO(D) IMMUNE GLOBULIN/MALTOSE WINRHO SDF VIAL    
TETANUS IMMUNE GLOBULIN/PF HYPERTET S-D SYRINGE    
TUBERCULIN,PURIF.PROT.DERIV. APLISOL VIAL